Numerous clinical practice guidelines have been developed to improve the quality and lower the cost of health care. Unfortunately, these guidelines often fail to be used in clinical practice. In an effort to enhance guideline utilization, the applicant has created a clinical decision support system (CDSS), known by the acronym SIEGFRIED (System for Interactive Electronic Guidelines with Feedback and Resources for Instructional and Educational Development), that utilizes a World Wide Web-based guideline server to lead a clinician interactively through a selected guideline algorithm to generate patient-specific care recommendations during a patient encounter. The guideline server is easily expandable to include new guidelines by storing guideline content and logic in a relational knowledge base. The content from this knowledge base is then incorporated into implementable programs using a generic code generator for guidelines. Extensive linkages to relevant educational and instructional resources on the Web are incorporated into the guidelines, including documentation to promote evidence-based medicine. The goal of this small project grant is to evaluate the clinical practice guideline system in a suitable environment in which computers are integrated into routine clinical workflow. The initial attempts to evaluate the impact of the guideline server on compliance with guideline recommendations, provider productivity and health care costs in a randomized controlled pilot study at the Duke Family Medicine Center failed because of low utilization. The preliminary data show that this low utilization resulted from inadequate integration of a computer-based system into a paper-based workflow. In general, providers were positive about the system's features and felt they would have used it if it were more integrated into the care documentation process. The applicant now proposes to implement and evaluate SIEGFRIED in two environments in which computers are routinely used for care documentation. Specifically, the impact of SIEGFRIED on compliance with guideline recommendations, provider productivity and health care costs will be assessed in controlled trials in an ambulatory care and an inpatient care setting at the Durham Veterans Administration (VA) Medical Center. The applicant has successfully implemented a test version of SIEGFRIED in Durham VA acute care clinic and received positive feedback from the care providers about the value of the system. This project extension has the potential to demonstrate the value of guideline-based CDSS in clinical care as well as inform us about the attributes of clinical sites that enable this type of technology to succeed.